Tuesday, November 18, 2014

Doctor shortage looming? Maybe not

Victoria Elizabeth Fischer was presented with a white coat by her grandfather, Dr. Christian Van Den Heuvel, at Georgetown University School of Medicine in August. The ceremony marks the start for each new class of medical students.

Lisa Helfert Courtesy of Georgetown University

The United States is facing a critical shortage of doctors that could seriously jeopardize the ability of a patient to get medical care in the coming years.

It's not hard to see how the group makes that calculation. Millions of people are getting health insurance for the first time under the federal Affordable Care Act. At the same time, 10,000 baby boomers are qualifying for Medicare every day, says Dr. Atul Grover, chief public policy officer of the AAMC.

"And we know, essentially, with the doubling of the population over the age of 65, over the course of a couple of decades, they're driving the demand for services," Grover says.

Others point out that the shortage isn't just about the absolute numbers of doctors needed. The demographics of the physician workforce are important, too, says Dr. Andrew Bazemore, who studies the primary care workforce for the Robert Graham Center, a think tank created by the American Academy of Family Physicians.

"And that means by their race and ethnicity," Bazemore says, "by their age, by their gender, and backgrounds. Do they actually look like and reflect the populations they are going to serve?"

But, while there may be agreement that the U.S. needs more primary care providers, it's not clear to everyone considering the problem whether all of those people need to be doctors.

"There are a lot of primary care services that can be provided by a lot of people other than primary care doctors," says health economist Gail Wilensky. She and a colleague recently led an expert panel that looked at the funding of advanced training for doctors.

Nonphysician primary care providers can include physician assistants, nurse practitioners, pharmacists and social workers, for example — often working together in teams with a medical doctor. Teams are thought to provide more cost-effective care, according to some health policy analysts. And, says Wilensky, more nonphysician health practitioners, each providing a different set of services, might lessen the need for more primary care doctors.

"What will we allow nurses to do — work up to the limits of their license?" Wilensky asks. "Work up to the limits of their training? What will we allow pharmacists to do? Those together would determine how many physicians it would be useful to have around."

Wilensky also points out that past studies predicting shortages of doctors have been laughably wrong.

"We haven't even been directionally correct sometimes," she says. "We thought we were going into a surplus and we ended up in a shortage — or vice versa."

Still, Atul Grover of the medical school association thinks it's better for society to err on the side that the shortage is real. "We don't think we should put patients at risk by saying, 'Let's not train enough doctors just in case everything lines up perfectly and we don't need them,' " Grover said in a recent C-SPAN interview.

But letting more people train to be doctors "just in case" strikes Wilensky and many other health economists as wasteful.

"Are you really serious?" Wilensky asks. "You're talking about somebody who is potentially 12 to 15 years post-high school — to invest in a skill set that we're not sure we're going to need?"

Training too many doctors could, potentially, jeopardize more than just the bank accounts of those being trained. Dr. Fitzhugh Mullan, a pediatrician and professor at George Washington University, says every doctor added to the health care system also adds cost.

"Training another doctor," he says, "isn't cheap — isn't cheap for the individual doing the training, isn't cheap for the institution providing the education, and ultimately isn't cheap for the health system. Because the more doctors we have, the more activity there will be."

Why, then, do so many physician groups continue to press for more doctors to be trained?

"The business model of an interest group is to create a sense of crisis," he says, "and then tell their constituents, 'We can help you.' "

There is one element of the debate that just about every expert agrees on — that the U.S. has to stop paying physicians based on the number and type of treatments and procedures they do, and instead base payment on how well they keep patients healthy. That might or might not reduce the need for more medical doctors. But it would almost certainly help close the payment gap between specialists and generalists.

"The physicians are the team drivers of the system," Wilensky says. "If you don't get that part right, either in terms of how they're trained or how they're paid, it's hard to imagine how health reform happens."

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Foxe's Book of Martyrs

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The greatest want of the world is the want of men, --men who will not be bought or sold; men who in their inmost souls are true and honest, men who do not fear to call sin by its right name; men whose conscience is as true to duty as the needle to the pole, men who will stand for the right though the heavens fall. -Education, p. 57. (1903)

Martin Luther

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Abraham Lincoln

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John Adams

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BENJAMIN FRANKLIN

GENERAL MARQUIS DE LAFAYETTE

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Edmund Burke

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Luigi Desanctis

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GALILEO GALILEI

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Miguel de Cervantes

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Frederick Douglass

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Sir Alexander Fraser Tytler

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Arturo Alfonso (Arthur) Schomburg

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John Emerich Edward Dalberg-Acton (Lord Acton)

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Pastor Martin Niemöller

First they came for the Jews, and I did not speak out, because I was not a Jew. Then they came for the Communists, and I did not speak out, because I was not a Communist. Then they came for the trade unionists, and I did not speak out, because I was not a trade unionist. Then they came for me, and there was no one left to speak out for me.

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ALDOUS HUXLEY

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Richard Maybury

Washington... has become an alien city-state that rules America, and much of the rest of the world, in the way that Rome ruled the Roman Empire.

Frank Zappa

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Sinclair Lewis

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THE HOLY INQUISITON

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Pierre Teilhard de Chardin S.J.

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Hillary R. Clinton

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Albert Pike

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Barack H. Obama

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Pat Robertson

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JIMMY CARTER

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Saul Alinsky

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Joseph Ratzinger

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GEORGE W. BUSH

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WILLIAM J. LEVADA

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CHARLES EDWARD COUGHLIN

On this earth you must belong to the church militant or get the hell out of it. That's the right word. You're either with me or against me' There is no middle ground in this battle between Christ and the anti-Christ. If you step out of (the battle), you're worse than those boys who ran off to Norway, Sweden, those boys who deserted the government. You're deserters, rotten deserters.

ROBERT SCHULLER

"It is time for Protestants to go to the shepherd (the pope) and say, `What do we have to do to come home?'" Dr. Robert Schuller, Los Angeles Herald Examiner, Sept. 19, 1987.

ADAM WEISHAUPT

Of all the means I know to lead men, the most effectual is a concealed mystery. The hankering of the mind is irresistible.

DAVID SPANGLER

No one will enter the New World Order unless he or she will make a pledge to worship Lucifer. No one will enter the New Age unless he will take a Luciferian Initiation.

ZBIGNIEW BRZENZINSKI

Soon it will be possible to assert almost continuous surveillance over every citizen and maintain up-to-date complete files containing even the most personal information about the citizen...

HENRY KISSINGER

"We will get a New World Order. We may not get it in our generation, but if we do not get it in our generation, we will get it in the next generation."